Testicular cancer: Full guide

What is testicular cancer?

The testicles (testes) are two glands in the scrotum. They make sperm and the hormone testosterone.

Testicular cancer starts when cells in a testicle grow out of control. It is the most common solid cancer in young men, ages 15 to 35. It can happen at other ages too.

Almost all testicular cancers are germ cell tumors. These start in the cells that make sperm. The two main kinds are seminoma and nonseminoma.

The most common sign is a painless lump or swelling in a testicle. Some people feel heaviness or a dull ache. A testicle that did not move down into the scrotum as a baby, and a brother or father with testicular cancer, raise the risk.

Testicular cancer is one of the most treatable cancers. It responds very well to chemotherapy, and seminoma also responds to radiation. Most people do very well, even when the cancer has spread.

Types

Seminoma

One of the two main kinds. It tends to grow slowly and often stays in the testicle. It responds very well to both chemotherapy and radiation. It never makes the marker AFP.

Nonseminoma

The other main kind. It often grows faster and is more likely to spread. It is often a mix of cell types. It responds very well to chemotherapy but not to radiation.

Types within nonseminoma

These include embryonal carcinoma, yolk sac tumor, choriocarcinoma, and teratoma. Your pathology report lists which ones are in your tumor.

Teratoma

A part of some nonseminomas that does not respond to chemotherapy or radiation. If it is left behind after chemotherapy, surgery is needed to remove it.

Mixed germ cell tumor

A tumor with more than one cell type. If it has any nonseminoma in it, it is treated as a nonseminoma.

Germ cell tumor outside the testicle

Rarely, these tumors start in the chest or the back of the belly. They are treated at centers with special experience.

Other rare testicular tumors

Leydig cell and Sertoli cell tumors start in hormone-making cells. Spermatocytic tumor is a rare, slow-growing germ cell tumor seen mostly in older men. These usually do not raise tumor markers. Surgery is often the main treatment.

Tests you may have

Scrotal ultrasound

Uses sound waves to look inside the scrotum. It is the first test for a lump. A solid mass is treated as cancer until proven otherwise.

Tumor marker blood tests

AFP, hCG, and LDH are measured before surgery, after surgery, and during follow-up. They help with diagnosis, staging, and tracking treatment.

Radical inguinal orchiectomy

Surgery to remove the whole testicle through a small cut in the groin. It is both the diagnosis and the first treatment. The testicle is never biopsied or removed through the scrotum.

CT scan

Detailed X-ray pictures of the chest, belly, and pelvis. It checks lymph nodes in the back of the belly, where this cancer often spreads first.

Chest X-ray

Sometimes used to check the lungs, along with or instead of a chest CT.

Brain MRI

Only needed for some people. Examples are very high markers or a lot of spread to the lungs.

PET-CT scan

Not used for routine staging. It may help check a leftover mass after chemotherapy for seminoma.

Semen analysis and sperm banking

Checks sperm count and stores sperm for the future. Ideally this is done before surgery or before any chemotherapy or radiation.

Hormone tests

Testosterone and related hormones may be checked, since the testicles make testosterone.

What the stage means

The stage tells if the cancer has spread and how far. It also uses your tumor marker levels after surgery.

Testicular cancer uses stages 1 to 3. Spread usually happens in a predictable order, first to lymph nodes at the back of the belly.

If the cancer has spread, doctors also place it in a risk group: good, intermediate, or poor. This uses the location of spread and the marker levels. Most people are in the good risk group.

Stage 1

The cancer is only in the testicle. Many people need no more treatment after surgery, only close follow-up. Some get a short course of chemotherapy to lower the chance it returns.

Stage 1S

The cancer seems to be only in the testicle, but markers stay high after surgery. This means some cancer is likely elsewhere. It is treated with chemotherapy.

Stage 2

The cancer has spread to lymph nodes at the back of the belly (retroperitoneal lymph nodes). Treatment may be chemotherapy, radiation for seminoma, or surgery to remove the nodes.

Stage 3

The cancer has spread to distant lymph nodes, the lungs, or other organs. Or the markers are very high. It is treated with chemotherapy based on the risk group.

Good risk group

The most common group. People in this group do very well with standard chemotherapy.

Intermediate and poor risk groups

Higher marker levels or spread to organs like the liver, bones, or brain. These need more chemotherapy, ideally at a center that treats many people with testicular cancer. Many people in these groups still do very well.

Tumor markers

Testicular cancer is one of the few cancers with very useful blood markers. They help confirm the type of cancer, set the stage, and show if treatment is working.

Markers are checked before surgery and again after. They are checked often during treatment and follow-up. A rising marker can be the first sign the cancer has come back.

Some things besides cancer can raise markers, such as liver disease or low testosterone. Your team will look at the whole picture.

AFP (alpha-fetoprotein)

Made by some nonseminomas, such as yolk sac tumors. Pure seminoma never makes AFP. If AFP is high, the cancer is treated as a nonseminoma, even if the report says seminoma.

hCG (human chorionic gonadotropin)

Made by choriocarcinoma, some other nonseminomas, and some seminomas. Very high levels can sometimes cause breast swelling.

LDH (lactate dehydrogenase)

A general marker of how much cancer is in the body. It is not specific to testicular cancer, but it helps set the risk group.

Markers after surgery

After the testicle is removed, markers should fall over a few weeks. If they stay high, cancer may be present somewhere else.

Isochromosome 12p

A change in the chromosomes found in most germ cell tumors. A lab test for it can help confirm the diagnosis in unclear cases.

Main treatments

Radical inguinal orchiectomy

Removing the testicle through the groin. Almost everyone has this first. You can ask about a testicular prosthesis (implant) for appearance.

Active surveillance

Close follow-up with exams, markers, and scans instead of more treatment right away. It is a preferred choice for many people with stage 1. If the cancer comes back, it can still be treated very well.

Chemotherapy

Medicines given by IV in cycles, usually every 3 weeks. Common combinations are BEP (bleomycin, etoposide, cisplatin) and EP (etoposide, cisplatin). Doses are kept full and on time because this matters for results.

Short-course chemotherapy for stage 1

For seminoma, one dose of carboplatin may be given. For nonseminoma, one cycle of BEP may be given. Each can lower the chance of the cancer coming back.

Radiation therapy

High-energy beams aimed at lymph nodes in the back of the belly. It is used for some seminomas that have spread to small nodes. It is not used for nonseminoma.

RPLND (lymph node surgery)

Retroperitoneal lymph node dissection removes lymph nodes at the back of the belly. It may be used for some stage 1 or 2 nonseminomas. Nerve-sparing methods help protect ejaculation.

Surgery for leftover masses

After chemotherapy for nonseminoma, if markers are normal, any mass 1 cm or larger is removed. It may hold teratoma, which chemotherapy cannot treat.

Treatment if cancer returns

Options include other chemotherapy combinations or high-dose chemotherapy with a stem cell transplant. In a transplant, your own stem cells are collected and given back. Surgery is also used. Many people still do well.

Clinical trials

Research studies testing new approaches. Ask if one fits your situation.

Common side effects and what helps

Fatigue

Very common during chemotherapy. Rest when needed and take short walks. Energy usually returns over weeks to months after treatment.

Nausea and vomiting

Anti-nausea medicines work well. Take them as directed, even before you feel sick. Eat small meals and drink fluids.

Low blood counts and infection

Chemotherapy lowers white blood cells. You may get shots to help your counts recover. Call right away for a fever.

Lung problems from bleomycin

Bleomycin can sometimes damage or scar the lungs. Do not smoke. Report new cough or shortness of breath. Tell any future surgeon or anesthesia team that you had bleomycin.

Hearing changes and ringing in the ears

Cisplatin can affect hearing. Tell your team about ringing or trouble hearing. A hearing test may be done.

Numbness and tingling

Cisplatin can cause tingling in the hands and feet. It often improves slowly. Tell your team if it gets worse.

Kidney effects

Cisplatin can affect the kidneys. You will get extra fluids with treatment. Drink plenty of water at home.

Fertility and sexual changes

Treatment can lower sperm count. Most people still have one healthy testicle. RPLND can sometimes affect ejaculation. Sperm banking before treatment protects your options.

Low testosterone

Some people have low testosterone after treatment. Signs include low energy, low sex drive, and mood changes. A blood test can check, and treatment is available.

Feelings and body image

Losing a testicle can feel hard. It is normal to feel worried or self-conscious. A prosthesis, counseling, and talking with other survivors can help.

Living with and after testicular cancer

Most people return to work, school, sports, and family life after treatment. Many go on to have children.

Follow-up is very important, especially in the first few years. You will have exams, marker tests, and scans on a set schedule. Do not skip them.

Check your remaining testicle each month. Tell your doctor about any lump or change. There is a small chance of cancer in the other testicle.

Chemotherapy can raise the long-term risk of heart disease. Do not smoke, stay active, eat well, and have your blood pressure, cholesterol, and blood sugar checked.

Treatment can rarely cause second cancers years later. Keep up with regular checkups and tell new doctors about your past treatment.

Brothers and sons have a higher risk. They should know how to check their testicles. Support groups for young adults with cancer can help with feelings, dating, and fertility questions.